global health

In the HIV/AIDS arena, theÂ idea of “treatment as prevention” has been gaining strength. Multiple studies have shown that treatment with anti-retroviral drugs can dramatically reduceÂ the likelihood that someone infected with HIV will be able to pass the virus to someone else.

Why? Because people everywhere can have trouble sticking to antiretroviralÂ treatment, even if drugs are available. And couples counseling by itself is valuable.

A powerful example of how this plays out, and of the importance of couples counseling to the effectiveness of antiretroviral drugs in prevention, comes fromÂ a recent presentation fromÂ Emory epidemiologist Kristin Wall at the AIDS 2014 meeting in Australia. The website NAM AidsmapÂ had a helpful write-up of her presentation, which isÂ available here.Â Thanks to co-author Susan Allen for alerting us to this.

CVCT (couples voluntary counseling and treatment) greatly enhanced the preventive effect of antiretroviral treatment, when compared to treatment without counselling, Wall’sÂ analysis of a large cohort of couplesÂ in Zambia showed.Â

Update: Allen points out that couples counselingÂ by itselfÂ was effective in helping people avoid HIV, with a 75 percent reduction in incidence for couples where the HIV+ partner was not receiving antiviral therapy or with HIV negative couples.Â Read more

The recent Westlake Forum III at Emory brought more than 250 leaders from Chinese and U.S. academic and government institutions together to examine and compare health care reform in the two countries, focusing on cost, quality, and access to care.

â€œThis was an incredible human partnership, bringing together two countries with very different governments and cultures, recognizing our common problems and desires for improved health of all our citizens, working together on difficult issues and exploring workable solutions,” said Jeff Koplan, director of the Emory Global Health Institute.

â€œNow China and the US are facing the same challenge: to push healthcare reform forward. Our two countries need to share knowledge and experiences with each other, and to learn from each other,â€ says Yu Hai, MD, PhD, director of China Medical Board Programs, Zhejiang University School of Medicine.

Howard Koh, assistant secretary for health, U.S. Department of Health and Human Services, presented an overview of U.S. health care reform.

In China, the government is committed to health care as a public good, with the goal of complete coverage by 2020. Although 90 percent of citizens are currently covered, cost and accessibility varies considerably. Hospital stays are longer than in the United States, medical training is less rigorous, and access to high-quality care is limited. As in the U.S., Chinaâ€™s public hospitals and providers struggle with the economic and quality issues generated by a â€œfee-for-serviceâ€ reimbursement mechanism.

Participants worked on developing concrete collaborations such as joint research, educational exchanges or partnerships.

Yet health care costs in China are only 5.13 percent of the countryâ€™s GDP, compared to 17 percent in the U.S.

William Roper, dean of the University of North Carolina School of Medicine and CEO of the UNC Health System, said health care in the United States is a â€œparadox of excess and deprivation,â€ and Americans need to rethink their long-held assumptions.

Americans believe they have the best health care system in the world, yet we spend more on medical care than any other country, we are the only rich democracy in which a substantial portion of citizens lack care, nurses are in short supply, quality and safety are not as high as they should be, and incentives for physicians are skewed toward specialization and expensive technical procedures, Roper said.

Harvard Professor William Hsiao noted that China has made significant progress in health care reform over the past seven years. In 2003, 75 percent of Chinese citizens were uninsured, whereas today China offers coverage on some level to 90 percent, with out-of-pocket payments continuing to decline. Problems persist in lack of well-trained physicians and equipment, distorted prices, and profit motives of public hospitals and officials.

Ken Thorpe, from Emoryâ€™s Rollins School of Public Health, outlined the newly passed U.S. health reform law, which aims to expand and improve coverage and access to quality care and control rising costs. Many of these improvements would likely be paid through Medicare reductions and increased taxes on higher income households, he said.

March Madness of a different flavor overtook Emory University March 18-19 as more than 200 students, judges, observers and staff convened for the first national Emory Global Health Case Competition.

The competition involved 20 teams of five students each, representing at least three academic disciplines per team. Emory fielded eight teams, and 12 teams came from leading universities across the country: Dartmouth, Princeton, Penn, Cornell, Yeshiva, Duke, Vanderbilt, UAB, USC, UCSF, Rice, and Texas A&M. All these universities are members of the Consortium of Universities for Global Health.

As in two past local and regional case competitions, this yearâ€™s event was student initiated, developed, planned, staffed and conducted.

This yearâ€™s signature sponsor was GE, with additional sponsorship from Douglas and Barbara Engmann, and internal Emory funding.

â€œGlobal health continues to grow as a primary interest of students at universities across the United States, and the Emory Global Health Case Competition has gained a reputation as the leading national team event to showcase the creativity, passion, and intellect of our future leaders in global health,â€ says Jeffrey Koplan, MD, MPH, director of the Emory Global Health Institute.

The Feb. 17, 2011 issue of The Lancet included an article by Koplan and Mohammed K. Ali, assistant professor of global health at Rollins School of Public Health on the benefits of problem-based competitions to promote global health in universities.

Teams worked through the night on Friday for their Saturday morning presentations. The case involved a proposal for improving conditions in several East African refugee camps in the face of a severe budget cut. Judges were blinded to the academic affiliations of the teams, but Emory won the top two prizes (first prize was $5,000). UCSF and Dartmouth received honorable mentions, and Rice was given an innovation award.

Jeffrey Koplan, MD, MPH, director of the Emory Global Health Institute and vice president for Global Health at Emory University, is leading the second phase of the Tobacco Free Cities project in China, funded by the Bill and Melinda Gates Foundation. The project, which launched in 10 Chinese cities this week, is a partnership with the ThinkTank Research Center for Health Development in Beijing.

Vice mayors of each of the 10 cities signed an official pledge to strive to create tobacco-free cities for residents. China has more than 300 million smokers, the most of any country, and more than 500 million people in China are exposed to secondhand smoke.

â€œThe two-year project aims to enhance the overall capacity in smoking-tobacco control of the cities and help ease the burden caused by tobacco to public health, the environment and the economy,â€ Koplan says in an article in China Daily.

The project launch was covered by other major Chinese news outlets, including Xinhua News Agency.

The first phase of the Tobacco Free Cities project launched in June 2009 in seven Chinese cities. The project is part of the Emory Global Health Institute-China Tobacco Partnership. In January 2009 Emory University received a $14 million, five-year grant from the Gates Foundation to establish the partnership.

As public health leaders from nearly 50 countries gathered this week at the Emory Conference Center, they had a common goal: strengthening individual public health institutes and establishing partnerships to significantly reduce death and disease globally.

The International Association of National Public Health Institutes (IANPHI) held its fifth annual meeting â€“ and the first in the United States â€“ in Atlanta, jointly hosted by IANPHI, located in the Emory Global Health Institute, and by the CDC. IANPHI is not a typical organization, pointed out IANPHI President Jeff Koplan. Itâ€™s a partnership of more than 80 members who are directors of CDC-like institutes around the world, and it exists for the partners to build relationships and actively support each other. IANPHI is funded by the Bill & Melinda Gates Foundation.

Jeffrey Koplan, MD, MPH, president of IANPHI

As the world â€œshrinksâ€ due to easier and more frequent air travel and migration, the effects on public health can be both positive and negative. On the negative side, communicable diseases and lifestyles that contribute to non-communicable diseases are transmitted much more rapidly around the world. But on the positive side, nations can work together much more efficiently to address public health challenges as committed partners.

Tom Frieden, director of the CDC, emphasized the importance of a national focus in each country on public health problems, and linking national efforts with local programs. Having adequate resources for public health will be essential in successful monitoring and disease response as well as driving down healthcare costs around the world, he said.

A major theme of the IANPHI conference was non-communicable diseases (NCDs) in addition to communicable diseases (CDs), which traditionally have been the focus of global public health efforts.Â NCDs now kill far more people than CDs throughout the world, Frieden pointed out. Â Significant progress can be made against NCDs with the right approach. Frieden gave the example of Uruguay, where 1 in 4 smokers quit smoking after a major public health effort.

Kevin DeCock, director of the CDCâ€™s new Center for Global Health, pointed out the fundamental changes in public health that have come about because of new technologies, such as cell phones and computers as well as new public health networks that allow much quicker responses. Only a few decades ago, information about disease outbreaks in less developed countries was communicated only after the disease had already peaked. Now that information can be sent almost instantaneously.

Public health leaders from four countries â€“ Nigeria, Guinea-Bissau, Tanzania, and Ethiopia â€“ gave examples of successful IANPHI-funded projects. Despite extremely limited resources in many countries, Koplan pointed out, these countries have made extraordinary and concrete progress in improving public health infrastructure and in decreasing disease and death from challenging public health problems.

The report was published in the Oct. 22 issue of Population Health Metrics. Edward Gregg, Emory adjunct professor of global health, and David Williamson, Emory visiting professor of global health, were co-authors.

The CDC’s projections have been a work in progress. The last revision put the number at 39 million in 2050. The new estimate takes it to the range of 76 million to 100 million.

The growth in U.S. diabetes cases has been closely tied to escalating obesity rates. A corresponding rise in diabetes has even prompted researchers to coin a new hybrid term: diabesity.

â€œThere is an epidemic going on that, if left unchecked, will have a huge effect on the U.S. population and on health care costs,â€ says K. M. Venkat Narayan, MD, MSc, MBA, professor of global health and epidemiology at the Rollins School of Public Health, who came to Emory from the CDCâ€™s Division of Diabetes Translation. â€œThe numbers are very worrying.â€

K. M. Venkat Narayan, MD, MSc, MBA

Narayan also heads the Emory Global Diabetes Research Center, which aims to find solutions to the growing global diabetes epidemic. The Center serves as the research leader and hub for population-based research and large intervention trials throughout South Asia and globally.

“Whatever we do, the fruits of our research have to be available to people everywhere,â€ says Narayan.

Read more about Dr. Narayan’s global efforts and diabetes research underway at Emory.

Meanwhile, Joseph Cubells,MD, associate professor of human genetics at Emory, shared his experience with the Mandarin Chinese Autism Spectrum Screening Questionnaire in urban Mandarin Chinese-speaking communities. Cubells says large-scale, community-based studies of autism spectrum disorders require effective tools for screening potential cases. So, to meet the need for such tools in Chinese populations, he and his colleagues translated and back-translated The Autism Spectrum Screening Questionnaire, a 27-item parental checklist originally published in English.

And what about incorporating global health education into the medical curriculum as a way of transforming universitiesâ€™ role in advancing global health? Emoryâ€™sHenry Blumberg, MD, professor of infectious disease and his colleagues have done just that. Now, global health is a part of Emoryâ€™s innovative new medical curriculum, which was launched in 2007. After all, global health is becoming ever more important to the world at large, garnering more interest from future physicians.

A higher level of education is associated with reduced risk of heart disease and stroke for people who live in rich countries, but not for those in low- and middle-income nations, according to the findings of a recent study led by Emory epidemiologist and cardiologist Abhinav Goyal, MD, MHS.

Abhinav Goyal, MD, MHS

The study published in the Sept. 7, 2010, issue of the journal Circulation, a publication of the American Heart Association, is one of the first international studies to compare the link between formal education and heart disease and stroke. It examined data on 61,332 people from 44 countries who had been diagnosed with heart disease, stroke, or peripheral arterial disease, or who had cardiovascular disease risk factors such as smoking or obesity.

Goyal and team found that highly educated men in high-income countries had the lowest level of cardiovascular disease. However, their findings suggest that research conducted in richer nations can’t always be applied to poorer countries.

“We can’t simply take studies that are conducted in high-income countries, particularly as they relate to socioeconomic status and health outcomes, and extrapolate them to low- and middle-income countries,” says Goyal, assistant professor of epidemiology and cardiology at Emoryâ€™s Rollins School of Public Health and Emory School of Medicine. “We need dedicated studies in those settings.”

The research team was surprised to find that despite decreased heart disease risk among the higher educated in industrialized nations, nearly half of the highly educated women from high-income countries smoked, compared with 35 percent for those with the least amount of schooling. For men, smoking rates were virtually the same across educational groups in low- and middle-income countries.

“Everyone needs to be educated about the risk of heart disease in particular, and counseled to adopt healthy lifestyles and to quit smoking,” Goyal says.

While in Atlanta, Chan also visited Emory to meet with President James Wagner and Emory Global Health Institute Director Koplan. She heard presentations about global health field projects by students in public health, medicine, and theology.

Chan recalled the â€œlost decade for development,â€ the 1980s, a dismal time for public health. The 1979 energy crisis followed by a recession made for tighter public health resources and few health care improvements worldwide, she explained. Some developing countries have still not recovered.

In contrast, public health has faired better in the new millennium, when the world has benefited from financial commitments backed by substantial resources, often from innovative sources, says Chan.Read more

A remarkably successful 20-year program of tobacco control in Hong Kong can serve as a best-practices example for China and other nations, says Jeffrey Koplan in an article published online today in The Lancet. Koplan is vice president for global health at Emory and director of the Emory Global Health Institute.

Hong Kongâ€™s successful tobacco control program began with a 1982 health ordinance launching a multi-step approach including legislative amendments (regulation of indoor smoking, pack warnings, ban on tobacco advertising), a steeply increased tobacco tax, school-based education, mass-media campaigns, community events, and leadership from the medical community.

Smoking prevalence in Hong Kong fell from 23.3 percent in 1982 to 11.8 percent in 2008 through the efforts of the Tobacco Control office of the Department of Health and NGOs such as the Hong Kong Council on Smoking and Health.